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Endovascular AVF creation | Twitter Case Files SIR 2019
Endovascular AVF creation | Twitter Case Files SIR 2019
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Interspinous Spacer | Twitter Case Files SIR 2019
Interspinous Spacer | Twitter Case Files SIR 2019

so this is our MGH page we started it about a year ago check it out if you guys like it some pretty good cases we mostly post cases some policy stuff industry and changing things it's not purely cases but certainly take a look if you like it give us a follow so what

I have today is I have two cases that I picked and you know for all the thousands of cases that all these huge academic medical centers do I tried to pick a couple that might be a little interesting and that aren't being done

in all the different centers across the institution so I'll start off with the first which is an endovascular AVF creation so what's nice about this is that you know what we see so far from this is that the length of stay impact

has been certainly reduced in certainly the maturation times and the Rhian turn re intervention rates have been reduced so I'll go through this and normally wouldn't go step by step for a few things but I think you know not all

institutions are doing this yet I think that you will I do think this is going to be a shift for a lot of the dialysis patients and everybody who works anion knows what a huge impact it is the ESRD patients is just astronomical the

numbers of them it's just continuing to rise so procedural steps the first step is you're going to access the brachial vein advance the guide Y down to the ulna insert a six French sheath and perform a vena Graham and the rationale

for that of course is to make sure you don't have any issues centrally some centers do that in advance some centers don't I will mention also that the ultrasound mapping is absolutely critical to make sure that

you get the right patient you start off by seeing them in the outpatient clinic and then you're going to go and have them have vascular ultrasound to make sure you have a good candidate so the next is you're gonna access the brachial

artery same thing advance your guide wire down to the ulna from there you're gonna insert the venous side now this is one of two approved vendors that will allow you to do an endovascular creation this was a wave link it's a to stick

system and it requires two catheters which is why you see the next step is pretty much repeated but just flipping it to the arterial side so from there there's a magnetic zone it actually has like a little canoe so it's got a

backing of a ceramic sort of a space there if you can think of sort of the older or atherectomy cut home catheters that had that little carro canoe you would actually take the debris out it's very

look into that and I'll show you that in a couple of images once you align that you're gonna sort of engage the little electrode this is an RF ablation RF created type fistula so it creates a little slit between the Adri and the

vein and what happens is is that you know of course don't forget you have to ground the patient just like any RF once you get the magnets and you get the electrode alignment you're going to engage the device for two seconds and

the fistula is created and then from there a lot of centers are actually going in there embolize in one of the brachial veins and this is basically to sum some of that stuff obviously to the superficial system for draining I have

read that there are a few places that actually go back back in through the newly-created fistula like even at the time of the procedure with the 4 millimeter balloon and just sort of open that up I'm not sure that that's 100%

necessary but I'm sure all these fine people on the panel could help us with that so here you see and I skipped all the entry steps but here you can see the Venus in the arterial catheter you know in position here and there's that little

canoe thing pointed out by the arrow that I had talked about and you use fluoro to sort of align these two things when you first start doing these cases take your time the first one was over an hour and a half for us now obviously

it's about a third at that time this is the little electrode this is when it's advanced and pretty much ready to engage can you play the video for me so this is quick so what happens is you suppress the

device the electrode actually advances and as it advances towards the veena side what happens is is that it actually just creates this fistula through the RF sort of energy from there you're gonna do a post vena graph in here you can see

after we did an initial post intagram there was enough sort of flow between the PIAT brachial so we decided to embolize one and this patient was our first patient and is doing very well so far this is done on I'm gonna say just

because you know to dr. brains point I don't want to get on the hook for certain dates and patient identification but this was done in mid-march so we saw them two weeks out and we're gonna see them again another couple weeks so just

there's a couple of trials that you can read into one is the neat one is the flex trial I think the technical success is really promising at 96% the maturation days you can see there's a massive massive comparison where they

could be ready to be dialyzed in 60 days and this could be a game-changer for many patients the six-month patency rate is what I've seen in most of the reports it's around 98% compared to about 50% with the surgical place and then you can

see that this about 3.5 interactions or re interventions that are required in about 0.5 at a year's time out from this so it's really making a big difference for these patients and I think this is what we do in i/o we continue advanced

things innovate and obviously look to do things in a more timely cost-effective minimally invasive way at the beginning when these new procedures come out the devices themselves might be at a higher price point but we'll see how that goes

moving forward as more and more vendors get into the space so the second case

that I have mr. case is failing new to us I don't think it's necessarily new worldwide but I found it interesting so I threw it in there so this is a

non-surgical patient this is a 92 year old guy this guy just simply asked dr. Hirsch one of our spine specialists when he saw him in clinic he was referred to us that you know all I really want to do dr. Hirsch no I'll never forget dr.

Hirsch she's a real good connector with his patients he turned him and said dr. Hurst's really all I want to do is take walks with my grandchildren which he was completely unable to do so I'm not sure that this is a crazy

complex case like some of the extreme interventions that you've seen earlier but it's certainly a meaningful case for certain patients so because of that you can see that this patient obviously had a frame role

narrowing and I'll blow up these images and show you what that looks like in really what we're trying to do here because really kind of a not necessarily a non-surgical candidate but certainly a high-risk or poor surgical candidate

because of some other coexisting morbidities so again as we get the degenerative process sort of advances you can see and stole this from Verta flex just to give them credit you can see that this like some inflammation

here are the nerves creating all kinds of issues with them being able to ambulate you have this it's a traditional setup like a vertebroplasty gonna put the patient prone access through the back you can start to see

the delivery device here there's no pointer on this but you can note that the vertebral bodies is a little bit narrowed here at least in this sort of graphical illustration here you're advancing the inner spine spacer what

happens is it's actually screwed to a rod that goes through the delivery system fairly large delivery system trying to get the exact French size from the vendor because I forgot it today what we found out is it's it's about the

size of a dime according to them so so this is what it looks like efforts deployed on the top of the device you can see sort of not the blue sort of struts of fuel but on the top of the device it's lining the spinous processes

here but you can see that that's where they actual receptacle for the screw piece of it the male piece of it actually gets screwed into it and then you unscrew it after you deploy it so that's how it's actually left behind and

then this is what it looks like in profile so you can see sort of the stabilization around the spinous process it fits right in between the spinous process in the transverse process so we've seen this patient twice he's doing

great he thinks dr. Hirsh all of a sudden is a god I think he did this case in about an hour but now he's spending time with these grandchildren and like you know when we think about it it's it's

probably the reason why 99% of the people actually got into this field so this is a real rewarding case so I threw this in there for people and so just the images plain film you can see on the left this is not a vascular case but you

can see he could use some help there too and it turns out that you know you can see on the EMR aside what's going on with his nerves this is what it looks like obviously the post-op picture I'm pretty

good position in here and then this is where it looks like in the lateral position and since I'm as interested in listening to these guys as you guys that's all I have I have two cases but before I end I do want to thank dr.

Zubin irani he trained at the dotter Institute he's a really innovative procedures he does a lot of a high-level cases and dr. Hirsch was a world-class spine person and before I walk off the stage I want to thank some of my team

who's here from MGH we have our inventory managers some of our technical managers in one of our techs and it's always a pleasure to be able to bring them here so thank you guys for everything that you do


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